Refers to the thickness of the ventricular myocardium. The wall may be thicker due to phyiological hypertrophy (athletes), pathological hypertrophy (hypertropic cardiomyopathy), infiltration (cardiac amyloidosis) or oedema (myocarditis).

Ejection fraction (EF)

• • Percentage of the volume of blood ejected per beat (normal is >52%)
  • This is a well validated measure of systolic function, but it can be misleading in certain disease states, particularly those that are characterised by a reduction in cavity size (absolute ejected volume may be reduced, despite a normal percentage).

Average global longitudinal peak systolic strain (GLPSS)

• • A measure of longitudinal systolic function (normal is ≥18%)
  • This value is the average longitudinal ‘strain’ (a measure of ‘deformation’ of the myocardium). Although it correlates with ejection fraction, it is a more sensitive measure for systolic dysfunction, particularly in certain disease states (i.e. chemotherapy and valvular heart disease).

Diastolic function is assessed via a combination of echocardiographic parameters including the ratio of ‘early mitral’ inflow to the ‘atrial kick’ inflow velocities, mitral inflow deceleration time, left atrial size and estimated systolic pulmonary pressure. There are four grades:

• • Grade 1: impaired relaxation (mild diastolic dysfunction)
    • This is a common finding in both males and females >60 years of age; importantly if there are no symptoms or no other echocardiographic evidence of elevated filling pressure, i.e. unexplained left atrial dilatation, then it may not represent an actionable pathology
  • Grade 2: pseudonormal filling (moderate diastolic dysfunction)
  • Grade 3: restrictive filling (severe diastolic dysfunction)
  • Grade 4: irreversible restrictive filling (very severe diastolic dysfunction)

There are reference ranges available for standardised measurements of RV cavity size (base, mid cavity and length from apex to base). Often cardiologists may elect to report this qualitatively (i.e. ‘normal size’ or ‘mildly increased’), as it is often quite difficult to accurately characterise with standard 2D echo.

Right ventricular dilatation is particularly important in pulmonary hypertension and when assessing the haemodynamic impact of atrial-level shunts.

Best measured from a dedicated zoomed image of the sub-costal 4-chamber (normal wall thickness is ~5 mm). This is often qualitatively reported. 

RV wall thickness is particularly important in the context of:

• • LV wall thickening: as involvement of both ventricles implies a diffuse process such as HCM or cardiac infiltration such as amyloid.
  • Elevated pulmonary pressure: as this implies a chronic process.

Tricuspid annular plane systolic excursion (TAPSE)

• • A measure (distance) of longitudinal systolic function (normal >16 mm)
  • This is a well validated measure of RV function (RV longitudinal motion is the major determinant of RV pump capability) and correlates well to prognosis in many disease states. It can be reduced in states of high RV afterload (pulmonary hypertension) or in disease of the RV myocardium.

Right ventricular S wave velocity (RVS’)

• • A measure (velocity) of longitudinal systolic function (normal >10 cm/s)
  • This is another measure of RV longitudinal function, but instead measures velocity instead of absolute distance (TAPSE). It is well validated and correlates with prognosis.

Right ventricular strain

• • The use of clinical use of strain assessment for the right ventricle is emerging.
  • In some situations it is a better assessment of true RV systolic function, as it is not affected by ‘tethering’ to the LV or ‘passive’ motion, such as TAPSE or RV S wave velocity.

Left atrial size and volume indexed to BSA

• • Normal LA volume is <34 mL/cm2

Right atrial size indexed to BSA

• • Normal RA area is <18 mL/cm2
  • Presence or absence of an inter-atrial communication (i.e. patent foramen ovale)

The number of cusps should be reported (i.e. trileaflet or bicuspid)

Leaflet mobility and presence of aortic stenosis

Leaflet competence (aortic regurgitation)

The mitral valve is a complicated structure, and should be thought of as consisting of leaflets (anterior and posterior), chordae, papillary muscles and an annulus. The anterior leaflet is the larger of the two and consists of 3 segments that oppose the 3 scallops (indentations in the leaflet tissue) that comprise the posterior leaflet

The presence, severity and mechanism should all be described in a standard report (of note, trivial mitral regurgitation is generally physiological, i.e. normal variant)

Primary mitral regurgitation – problem with the leaflet

Secondary mitral regurgitation – leaflet structure is intact, but the MR is due to a secondary mechanism such as dilatation of the annulus or papillary muscle dysfunction (as seen in ischaemic heart disease)

Presence or absence of tricuspid regurgitation and stenosis should be mentioned

Estimation of pulmonary pressure

• • This can sometimes be a confusing aspect of the report to the reader
  • Right ventricular systolic pressure (RVSP) or systolic pulmonary artery pressure (SPAP)
  • RVSP is a surrogate for the systolic pulmonary pressure (in the absence of RVOT obstruction / stenosis).  It requires the addition of an estimated of right atrial pressure (RAP) which is determined by the size and respiratory variation of the inferior vena cava (IVC)

Often not well visualised (however generally speaking right-sided valves are seen better with trans-thoracic echocardiography than via trans-oesphageal echocardiography)

The presence or absence of regurgitation and stenosis should be mentioned

Sometimes the pulmonary artery may be enlarged in conditions such as pulmonary hypertension

Size of the aortic root, proximal ascending aorta and aortic arch should be mentioned. The aorta may dilate in conditions such as hypertension or aortopathies such as those seen with bicuspid aortic valves and Marfan’s syndrome.

Normal reference ranges depend on sex, body surface area (except in extreme obesity) and age (often useful to use an indexed value or a Z-score for children / adolescents):

• • Normal male ascending aorta size = 30 mm ± 4 mm (indexed is up to 1.5 ± 2 mm/m²)
  • Normal female ascending aorta = 27 mm ± 4 mm (indexed is up to 1.6 ± 3 mm/m²)